Middle East Respiratory Syndrome Coronavirus

(MERS-CoV)

Zack Moore, MD, MPH May 20, 2014

Coronaviruses (CoVs)

• Human CoVs first isolated in the 1960s • Six human CoVs identified to date:

– HCoV-229E – HCoV-OC43 – HCoV-NL63 – HCoV-HKU1 – SARS-CoV – Middle East Respiratory Syndrome Coronavirus

(MERS-CoV)

http://www.bt.cdc.gov/coca/ppt/2013/06_13_13_MERSCoV_FINAL.pdf

Non-SARS Human CoVs: Epidemiology

• Worldwide • Winter and spring in temperate climates • Exposure common in early childhood • Droplet, contact, and indirect contact • Symptoms and viral loads high first few days

of illness • Incubation period 2–5 days

http://www.bt.cdc.gov/coca/ppt/2013/06_13_13_MERSCoV_FINAL.pdf

Non-SARS Human CoVs: Clinical Spectrum of Illness

• Most often associated with upper respiratory tract infections in children

• Pneumonia and lower tract infections in immunocompromised individuals and the elderly

• May play a role in exacerbations of underlying respiratory diseases

http://www.bt.cdc.gov/coca/ppt/2013/06_13_13_MERSCoV_FINAL.pdf

SARS

• First recognized Nov, 2002 as sporadic cases in Guandong province, China

• Outbreak period 2002–2003 • Hong Kong hotel contributed to spread of

virus to several countries • 8,098 probable SARS cases

– 774 deaths (10%)

http://www.bt.cdc.gov/coca/ppt/2013/06_13_13_MERSCoV_FINAL.pdf

SARS: Epidemiology

• Incubation period 2–10d (median 4d) • Droplet transmission

– Aerosol spread? – Fomites? – Fecal-respiratory transmission at an apartment

complex in Hong Kong • Transmission most likely during 2nd week of

illness • Super spreading events

http://www.bt.cdc.gov/coca/ppt/2013/06_13_13_MERSCoV_FINAL.pdf

Middle East Respiratory Syndrome

Images: www.cdc.gov

Case #1: June 13, 2012 • 60 year-old man from Saudi Arabia • 7 days of fever, cough, shortness of breath

Hospital Day 1 Hospital Day 3

N Engl J Med 367;19, Nov 2012

Case #2: September 9, 2012

• 49 year-old man from Qatar – Recent travel to Saudi Arabia – History of farm (camels and sheep) exposure

• 6 days of cough, myalgia and arthralgia • Admitted to Qatari hospital with bilateral

pneumonia • Transferred to London for respiratory and

renal failure

Eurosurveillance, Vol. 17:40, Oct. 4, 2012

MERS-CoV: Identification

• Viruses from cases 1 and 2 99.5% identical

MERS-CoV: Background

• First identified in September, 2012

• Cases retrospectively identified as early as March 2012

• Different from other coronaviruses in humans, including SARS

• Most similar to coronaviruses found in bats

MERS-CoV: Origins

• Several studies have identified MERS-CoV in high proportion of camels – Likely reservoir

• Identical gene segment found in one bat

• Mode of transmission unclear – Respiratory? Foodborne? – Few primary cases with direct

camel contact

MERS-CoV Identification in Camels

http://wwwnc.cdc.gov/eid/article/20/8/14-0590-f2.htm

MERS-CoV: Clinical • Range of presentations*

– 62% severe respiratory illness – 5% mild symptoms – 21% asymptomatic

• Data from early cases – High mortality – Lower respiratory tract illness, fever

• Data from more recent cases – Lower mortality – Higher proportion with upper respiratory tract illness

• No vaccine, no specific treatment

Cases with available data through 5/9/14; WHO

PresenterPresentation Notes62% of cases involved severe respiratory illness requiring hospitalization, 32 (5%) occurred in persons who had mild symptoms or illness not requiring hospitalization and 110 (21%) were asymptomatic

MERS-CoV: Epidemiology

• Case demographics – 65% male – Median age 49 years (9 months–94 years)

• Incubation period 2–14 days • Infectious period

– Under investigation – Not believed contagious before onset

MERS CoV: Transmission

• ~75% identified as “secondary” – Mostly healthcare workers (19% of all cases) – Many with no or minor symptoms

• Many clusters identified – Healthcare – Household (estimated 1.3% secondary attack rate)

• No sustained person-to-person transmission

• 614 cases* – 181 deaths (29%)

• Majority of case in Saudi Arabia

• Other affected countries – United Arab Emirates, Qatar, Oman, Jordan,

Kuwait, Yemen, Lebanon – UK, France, Turkey, Tunisia, Italy, Greece, Malaysia,

USA, Egypt, Netherlands

MERS Co-V: Current Status*

*WHO, May 19, 2014

MERS-CoV Cases by Country of Presumed Exposure

MERS-CoV Cases by Country of Residence

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm63e0514a1.htm

Source: WHO

MERS-CoV: Epidemic Curve

MERS-CoV Cases by Case Type

MERS in the United States

• First case confirmed May 2, 2014 – HCW from Saudi Arabia – Diagnosed and hospitalized in Indiana

• Second case confirmed May 11, 2014 – HCW from Saudi Arabia – Diagnosed and hospitalized in Florida

Volume of Travelers from Saudi Arabia and the United Arab Emirates, April-May, 2014

PresenterPresentation NotesFive cities in the United States accounted for 75% of arrivals from Saudi Arabia and UAE; approximately 100,000 travelers are estimated to arrive in these five cities from Saudi Arabia and UAE in May and June 2014.

MERS-CoV: Public Health Actions

Contact Epi On-Call immediately for any patient in whom MERS is considered

Patient Under Investigation: A • Fever and pneumonia or acute respiratory distress

syndrome

AND EITHER

• Travel from affected region within 14 days before symptom onset

OR

• Close contact with a symptomatic traveler

OR

• Member of a cluster of patients with severe acute respiratory illness of unknown etiology in which MERS-CoV is being evaluated

Patient Under Investigation: B

• Close contact with a confirmed or probable case of MERS while the case was ill

AND

• Fever (>100°F) or symptoms of respiratory

illness within 14 days following the close contact. (lower threshold than category A.)

MERS-CoV: Close Contact Definition

• Provided care for a MERS patient – Healthcare worker – Family member – Similarly close physical contact

• Stayed at same place (e.g. lived with, visited)

as MERS patient while the patient was ill

MERS-CoV: Testing

• Available at SLPH with prior approval • Guidance available on DPH website

MERS-CoV: Infection Control

• Healthcare settings – Contact, droplet and airborne isolation

• Fit-tested N95 or higher level respirators • Gowns, gloves and eye protection • Negative-pressure airborne infection isolation

– Surgical mask when out of room • Home

– Follow guidance for ill persons, care givers and close contacts

http://www.cdc.gov/coronavirus/mers/infection-prevention-control.html

MERS: Isolation and Quarantine

• Recommendations evolving – Voluntary home quarantine used for close contacts to

IN and FL cases – Other contacts asked to self-monitor if asymptomatic

• Based on degree of risk

– Higher risk: Household contact and HCWs with unprotected exposures

– Lower risk: Travel contacts, ED patient contacts, community contacts

CDC Travel Alert Level 2

• Travelers going to provide health care services are advised to practice CDC’s recommendations for infection control of confirmed or suspected cases and to monitor their health closely

• Travelers who are going for other reasons are advised to follow standard precautions, such as hand washing and avoiding contact with people who are ill

Summary

• New virus with high case-fatality rate • Spreads person-to-person but no sustained

transmission • Rapid increase in number of cases during

Spring 2014 – First US cases identified May 2014

• Need for provider and public education to increase chances of early detection

Middle East Respiratory Syndrome Coronavirus �(MERS-CoV)Coronaviruses (CoVs) Non-SARS Human CoVs: EpidemiologyNon-SARS Human CoVs:�Clinical Spectrum of IllnessSARSSARS: EpidemiologyMiddle East Respiratory SyndromeCase #1: June 13, 2012Case #2: September 9, 2012MERS-CoV: IdentificationMERS-CoV: BackgroundMERS-CoV: OriginsMERS-CoV Identification in CamelsMERS-CoV: Clinical MERS-CoV: EpidemiologyMERS CoV: TransmissionMERS Co-V: Current Status*MERS‐CoV Cases by Country of �Presumed ExposureMERS‐CoV Cases by Country of �ResidenceMERS-CoV: Epidemic CurveMERS-CoV Cases by Case TypeMERS in the United StatesVolume of Travelers from Saudi Arabia and the United Arab Emirates, April-May, 2014MERS-CoV: Public Health ActionsPatient Under Investigation: APatient Under Investigation: BMERS-CoV: Close Contact Definition MERS-CoV: Testing MERS-CoV: Infection ControlMERS: Isolation and QuarantineCDC Travel Alert Level 2 SummarySlide Number 33